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| LETTER TO EDITOR |
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| Year : 2015 | Volume
: 63
| Issue : 4 | Page : 611-612 |
Commentary: Epithelioid hemangioma of spine
Abrar Ahad Wani
Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| Date of Web Publication | 4-Aug-2015 |
Correspondence Address:
Abrar Ahad Wani
Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.162083
How to cite this article:
Wani AA. Commentary: Epithelioid hemangioma of spine. Neurol India 2015;63:611-2 |
Sir
Angiolymphoid hyperplasia with eosinophilia was a name given to a rare endothelial cell tumor which the World Health Organization later on designated as epithelioid hemangioma (EH). [1],[2] The authors have drawn attention to an entity, which is relatively unheard of in neurosurgical practice. I would like to emphasize the differential diagnosis of EH about which the description provided in the manuscript is not adequate. [3] One has to differentiate EH from a conventional vertebral hemangioma (VH), an epithelioid hemangioendothelioma (EHE), and an angiosarcoma (AS).
Radiologically, the difference is not clear except that increasing bone destruction and soft tissue involvement is found as one moves down the spectrum from VH to EH to EHE to AS. Although some other differences are mentioned in the literature, they are not widely accepted.
In the absence of diagnostic and radiologically differentiating signs, it is histopathology supplemented with immunohistochemistry, that differentiates the entitites. VH may be of capillary or cavernous type. The cavernous type comprises multiple, large, thin-walled vascular spaces lined by flat endothelial cells. The capillary type is composed of numerous capillary channels lined by plump uniform endothelial cells and separated by a reactive fibrous tissue. The adipose tissue is variable in amount. [3]
In EH, the vascular structures are lined by a single layer of plump, epithelioid endothelial cells with abundant eosinophilic cytoplasm in a loose, paucicellular collagenized background. Rarely mitoses are seen, there is only mild cellular atypia, and they stain positive for CD31 and CD 34. [4]
In EHE, the epithelioid endothelial cells form nests or cords and lie in the loose hyalinized stroma. They have abundant eosinophilic cytoplasm and often have intracytoplasmic vacuoles. Unlike normal endothelial cells, they have abundant intermediate filaments and stain for vimentin and often to cytokeratin as well. In AS, sheets of cells with irregular vascular channels and plenty of atypia and pleomorphism are seen. The degree of vascularity is much more than seen in EH and EHE. Foci of necrosis are typical of AS. [5],[6],[7],[8]
There are no clear guidelines for this tumor and treatments ranging from wide en bloc resection, curettage, embolization, radiotherapy, and just observation have been described in literature. [1]
In this interesting article, the authors have nicely described the case and have managed it well. It would be interesting to know the status of tumor recurrence after some more time has lapsed, If at all the tumor recurs, there are three available options: Immediate re-operation, observation with serial imaging, or radiotherapy.
I would like to differ with authors on the extent of resection in these tumors. If surgery is indicated than in the case of a surgically accessible lesion, complete excision is desirable to prevent recurrence. The institute's experience in dealing with this type of lesion, however, must be taken into consideration for the patient's safety.
| » References | |  |
| 1. | Boyaci B, Hornicek FJ, Nielsen GP, DeLaney TF, Pedlow FX Jr, Mansfield FL, et al. Epithelioid hemangioma of the spine: A case series of six patients and review of the literature. Spine J 2013;13:e7-13.  |
| 2. | Nielsen GP, Srivastava A, Kattapuram S, Deshpande V, O′Connell JX, Mangham CD, et al. Epithelioid hemangioma of bone revisited: A study of 50 cases. Am J Surg Pathol 2009;33:270-7. |
| 3. | Fox MW, Onofrio BM. The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J Neurosurg 1993;78:36-45. |
| 4. | O′Shea BM, Kim J. Epithelioid hemangioma of the spine: Two cases. Radiol Case Rep 2014;9:984. |
| 5. | Hurley TR, Whisler WW, Clasen RA, Smith MC, Bleck TP, Doolas A, et al. Recurrent intracranial epithelioid hemangioendothelioma associated with multicentric disease of liver and heart: Case report. Neurosurgery 1994;35:148-51. |
| 6. | Kleer CG, Unni KK, McLeod RA. Epithelioid hemangioendothelioma of bone. Am J Surg Pathol 1996;20:1301-11. |
| 7. | Aquilina K, Lim C, Kamel MH, Marks CJ, O′Sullivan MG, Keohane C. Epithelioid hemangioendothelioma of the spine. Report of two cases. J Neurosurg Spine 2005;3:393-9. |
| 8. | Ahmed S, Epari S, Shah M, Rao KS. Epithelioid hemangioendothelioma of sphenoid bone: A case report of an unusual case. Neurol India 2012;60:344-6. [ PUBMED]  |
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